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STATE OF CALIFORNIA / STATE WATER RESOURCES CONTROL BOARD c5' UNDERGROUND STORAGE TANK PER IT APPLICATION • FORM B COMPLETE A SEPARATE FO FOR TANK SYSTEM. MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMI N CL SI e TEMPORARY TANK CLOSURE 6 TAA NK K RE VED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED 8V: C. DATE INSTALL (MID/DAV/YEAq) D. TANK CAPACITY IN G 0NS: II.TANK 06TENTS IFA-1 IS MARKED,COMPLETE ITEM C. LIFF MOTOR VEHICLE FUEL ❑ 4 OIL B, C 1a REGULAR 3 DIESEL PETROLEUM 60 EMPTY 1 PgpDUCT ❑ 1b PREMUNLEADE ❑ 6 AVIATIONGAS 4 GASAHOL CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL 7METHANOL 2 LEADED ❑ CRIBE IN ITEM D. BELOWI NOT=MARKED. NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S.AND C,AND ALL THAT APPLIES IN BOX D AND [A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 95 UNKNOWN d SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE W/FRP rimary T. ❑ g BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 5 GLASS LINING ❑ 4 PHENOLIC LINING LINING E71 ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) — _ OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE [CO:RROSION PE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY TION A U A u 99 OTHER 1 SINGLE WALL A U 2 DOUBLE WALL p U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE N A U 5 ALUMINUM A U 6 CONCRETE N I U 7 STEEL 5 COATING A U 6 100% METHANOL COMPATIBLE W/FRP 57 U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U g5 UNKNOWN CTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING A U 99 OTHER ❑ 3 MONgORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION. ❑ 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/VR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING3_WAS TANK FILLED WIT GALLONS INERT MATERIAL YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG , IS TRUE A D CORRECT APPLICANTS NAME (PRINTED BSIGNAtURE) D E LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOU NUMBERS BELOW OUN # JURISDICTION# FACILITY# STATE IBM � TA # PERMIT NUMBER PERMIT APPROVED BY/ TE ERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FHL FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 J / FORDUN&R6